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The Bishop of Carlisle and organ donation

by
18 May 2011

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From Dr David W. Evans and Dr Michael Banner

Sir, — I am concerned that the Bishop of Carlisle, the Rt Revd James Newcome, speaking for the Church of England (News, 6 May), appeals to us all to donate our organs for transplantation without reference to the vexed question when it may be permissible to remove them from what are, of necessity, still-living bodies; for death, as it is commonly understood, cannot be awaited if the organs are to be capable of function in other bodies for many years.

That difficulty — the fact that one cannot obtain viable complex organs from truly dead bodies — has beset transplantation practice from the first, and has spawned numerous attempts to redefine human death in forms that anticipate the unequivocal and universally recognised state.

One of those redefinitions is based on the concept that when the whole of the brain is dead the person can be considered dead, although his or her body still functions normally. That concept has found favour in many parts of the world, and particularly in the United States, where it is a basis for the legal certification of death on statutory grounds — although the concept and the means of diagnosis of so-called “whole brain death” are still actively debated.

In the UK, the commonly used redefinition of death for organ-transplant purposes is a lesser degree of permanent brain damage — so-called “brain-stem death” — which is held to be sufficient to ensure that there can never again be any form of consciousness, although the scientific basis of that claim is insecure, and the prescribed tests for the diagnosis of this syndrome are less than stringent. This reductionist version of brain death has never been accepted as sufficient for the diagnosis of death in the US, and has recently been specifically rejected by the Chief Rabbi.

Other redefinitions of death are now coming into wider use as those based on neurological damage come under greater scrutiny and are found wanting, e.g. by the US President’s Bioethics Council in 2008. Those based on brief cessation of circulatory function are hotly contested, and seem destined to fail in their turn, particularly on grounds of reversibility.

The purpose of rehearsing the arbitrary nature of the diagnosis of death for transplant purposes is to remind people, or perhaps make known to them, that the words “after my death” on the NHS Organ Donor Register application form do not mean after death in the time-honoured and still commonly understood sense.

Those offering their organs in the belief that they will be permanently without a heartbeat, not breathing, cooling and stiffening a bit maybe, and certainly unconscious — the state everywhere recognised as death — before they are operated on will have made the offer on a false premise. When told that they will, in fact, still have their natural heart­beat throughout, be breathing still with the continuing aid of a ventilator, be so reactive that they will have to be paralysed to facilitate the surgery, and may be given anaesthesia by some concerned anaesthetists, they may feel that they have been deceived.

Consent to organ removal after death, however obtained and recorded, must be fully and fairly informed if it is to be valid. It may be that some of the millions whose names are already on the NHS Organ Donor Register are not fully aware of what it is that they are deemed to have agreed to when in a state very different from death as they may have envisaged it.

It should be a matter of grave concern to the Church that others are being persuaded to register without the caveat that they must clearly understand the true nature of the offer they record thereby.

DAVID W. EVANS
Queens’ College
Cambridge CB3 9LN

MICHAEL BANNER
Dean and Fellow
Trinity College
Cambridge CB2 1TQ

From Dr David J. Hill

Sir, — Before retiring as a consult­ant anaesthetist, I was involved in major-organ transplantation. Three things were clear.

First, a very limited selection of doctors was used to diagnose death for transplant purposes. Those, like myself, who could perform the required tests but would not make the diagnosis of death would not be invited.

Second, colleague anaesthetists, and the protocol of my department of anaesthesia at the time, advocated full general anaesthesia for the organ donor, although he or she had been diagnosed as dead.

Third, theatre registers would sometimes record the time of death of the donor as the time when the ventilator was turned off at the end of the procedure. Clearly, some theatre personnel involved in the organ-procurement operation did not regard the donor as dead at the commencement of the donor operation.

I did not, and do not, believe that the majority of those persuaded to sign up as donors are made aware of these paradoxes, which may well influence their decision to donate, and the Bishop’s encouragement of us to do so.

DAVID J. HILL
The Old Post House, Eltisley
Huntingdon
Cambridgeshire PE19 6TG

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